While vasopressors are typically administered through a central venous catheter (CVC), peripheral intravenous (PIV) administration is becoming more common in clinical practice. The safety of this administration method is now well-established and is a good alternative to CVC placement for vasopressin administration especially at low-moderate dose vasopressors used for a short duration.
In this article, we will review the latest evidence on the safety of administering vasopressors through a PIV, including the incidence of adverse events and the factors that may affect their safety. We will also discuss the implications of these findings in clinical practice and the need for further research in this area.
Common Protocol Criteria for PIV Administration of Vasopressors
Based on a clinical study, the advised protocol for PIV administration of vasopressors is as follows:
Identify the IV site and ensure the proper positioning of the patient’s extremity.
With the guidance of ultrasound for the insertion of the peripheral IV catheter, employ a longer catheter length (>/=1.75 inches) if feasible. Confirm its placement with an ultrasound flush test.
Avoid High-Risk Areas
Avoid inserting the IV in high-risk areas such as the hand or wrist and ensure that the site is below the antecubital fossa (AC).
Blood Pressure Cuff
When using an inflatable blood pressure cuff, place it on the other extremity to control pressure on the IV site.
Select an 18 or 20-gauge IV, or even a larger bore size if available. It must not occupy 45% to 50% of the blood vessel in the ultrasound.
Check the IV and the peripheral vasopressors every 2 to 4 hours or at appropriate intervals.
Ensure a backup IV is available in case the first one becomes tenuous.
Verify that the necessary antidotes are available at the healthcare facility. Substances such as nitro paste and phentolamine mesylate (Regitine) will be necessary in case of vasopressor extravasation.
Risks Associated With PIV Administration
A 2021 review investigated the safety of administering vasopressors through a PIV among patients of any age in acute care settings. It included 23 studies that involved 16,443 patients.
The results showed that the incidence of local anatomic adverse events associated with PIV vasopressor administration was low and had a pooled incidence proportion of 1.8% in adults and 3.3% in children. Subgroup analyses did not identify any significant effects related to differences in clinical location, risk of bias, PIV location and size, and vasopressor type or duration.
However, the majority of the studies had some concerns regarding their risk of bias. Further research is required to evaluate the effects of PIV location and size, vasopressor type and dose, and patient characteristics when it comes to the safety of PIV vasopressor administration.
Comparison between CVC and PIV
Another 2021 article in the Journal of Medical and Clinical Nursing sought to compare the use of peripheral and central venous catheters among critically ill patients in terms of venous pressure and complications.
Comparison of Venous Pressure
The study found that central venous catheters were associated with higher venous pressure than peripheral venous catheters. This was likely due to the larger diameter of the central veins and the closer proximity of these veins to the heart.
However, the increase in venous pressure did not result in significant differences in overall complications between the two types of catheters.
Complications Associated With Catheters
Complications associated with both types of catheters included catheter-related bloodstream infections, thrombosis, and mechanical complications such as catheter dislodgement or occlusion. The incidence of these complications did not differ significantly between the two types of catheters.
Considerations for Choosing a Catheter Type
The study suggests that peripheral and central venous catheters can be used in critically ill patients, but clinicians should carefully consider the risks and benefits of each approach for individual patients.
Factors such as the expected duration of catheterization, the underlying medical condition of the patient, and the risk of infection or thrombosis should be taken into account when deciding which type of catheter to use. Close monitoring for complications is also important for both types of catheters.
Analyzing Risk Vs Benefit of PIV Administration
Use of Central Venous Catheters
The most common route of administration for potentially high-risk medications is via a CVC. It provides direct access to the central circulation and enables the administration of higher volumes and concentrations of medications.
However, CVCs are also associated with a higher risk of complications, including catheter-related bloodstream infections, thrombosis, and mechanical complications.
Peripheral Intravenous Catheters
PIVs are an alternative route of administration for potentially high-risk medications that may be considered in certain circumstances. PIVs are less invasive than CVCs, are easier to insert, and are associated with fewer complications. However, they have several limitations, including lower flow rates, limited infusion volumes, and a higher risk of infiltration and extravasation.
A risk-benefit analysis can be used to evaluate the potential benefits and risks of using PIVs for the administration of medications in critical care. Factors that should be considered include the severity of the patient’s illness, the specific medication being administered, the expected duration of treatment, and the risk of complications associated with PIVs and CVCs.
Considerations for Use
Overall, the use of PIVs for vasopressor administration in critical care should be carefully considered on a case-by-case basis. In certain circumstances, such as for short-term infusions or in patients with limited venous access, PIVs may be a reasonable alternative to CVCs.
However, in critically ill patients requiring long-term or high-volume infusions, CVCs may be necessary to ensure the safe and effective administration of these medications. Close monitoring and appropriate interventions should be in place to minimize the risks of complications associated with PIVs and CVCs.
Although the peripheral administration of vasopressors is associated with certain complications, it can be a safer and effective alternative to central venous access in some circumstances.
However, the decision to use peripheral vasopressors should be made with caution. The patient’s condition, the potential risks and benefits, and the experience of the healthcare provider must be taken into account.
PIV vasopressor administration is one of the many hospital procedures included in the Hospital Procedures Consultants’ (HPC) course. By enrolling, you can refresh and update your knowledge with evidence-based procedural education for emergency and hospital scenarios.
Explore HPC’s website for live, online, and custom courses.
Owen, V. Rosgen, B. Cherak, S. Ferland, A. Stelfox,H. Fiest, K. Niven,D. Adverse events associated with administration of vasopressor medications through a peripheral intravenous catheter: a systematic review and meta-analysis. Crit Care. 2021. 16,25(1)
Howthan,A. El-Hady, M. Mersal, N. Comparison Between Peripheral and Central Venous Catheters Regarding Venous Pressure and Complications among Critically Ill Patients. Journal of Medical & Clinical Nursing. 2021. 6
Lewis, T. Mercan,C. Altshuler,D. Papadopouls,J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med. 2019. 34(1)
Tian,D. Smyth,C. Keijzers,G. Macdonald,S. Peake,S. Udy,A. Delaney,A. Safety of peripheral administration of vasopressor medications: A systematic review. Emerg Med Austalas. 2020. 32(2) 220-227